Improving integrated care for older people with frailty and their carers: An ethnographic study of medicines-related care within an integrated care pa

Background
Integrated care pathways (ICPs) are 'locally developed, multidisciplinary infrastructural technologies that map core interventions in a clinical trajectory and are simultaneously a workflow system and a record of care' (Allen 2014: 808). ICPs have been widely used to improve quality and equity of care for patients with a range of health conditions. They have been proposed as a vehicle for clinical governance (Degeling et al 2005), embedding evidence based guidelines into clinical practice (Allen 2014), and health care policy. However, there has been limited social science research focusing on a critical understanding of the role, value and implications of ICPs from different stakeholder perspectives, and the social, organisational, politico-economic and historical contexts shaping their emergence, development and implementation in practice.

This PhD study will explore these issues in the context of ICPs for frail older people in Lambeth and Southwark, South London. Frail older are high users of health and social care services, but report difficulties receiving care efficiently and in a coordinated manner, and are at high risk of receiving poor quality of care due to fragmented service provision (Ament et al 2014). Although a number of ICPs for frail older people are being developed, evaluated and commissioned locally in the UK, little is known about different stakeholders' perspectives of the benefits, limitations and unintended consequences of ICPs, and the contexts shaping their development and implementation in practice.

Aims
1) To examine the social, organisational, politico-economic and historical contexts shaping the emergence, development and implementation of ICPs for frail older people;
2) To explore how ICPs for frail older people in Lambeth and Southwark, South London are currently being delivered and implemented on the ground;
3) To explore how frail older people and their family carers, and different provider and organisational stakeholders perceive ICPs, including their role, value, limitations and implications.
4) To synthesise knowledge from 1-3 to co-design clearer pathways and inform a framework to facilitate the implementation of ICPs, that meet the needs of what is important to frail older people, and improve quality of care and outcomes for frail older people in Lambeth and Southwark, South London.

Methods
The study will use a mixed-methods design:
1) A genealogical analysis of health care policy of the historical and politico-economic discourses, practices and contexts shaping the emergence of ICPs for frail older people.
2) An ethnographic study to explore how ICPs for frail older people in Lambeth and Southwark, South London are currently delivered locally. This will involve observations of care practices with a sample of frail older people and their family members as they navigate the health and care system, analysis of care records, interviews with participants and professionals involved in their care and pathway mapping.
3) Co-design methodology will subsequently be applied through a series of group workshops with a range of stakeholders to develop clearer pathways and a framework to facilitate the implementation of ICPs to improve quality of care and outcomes for frail older people.

References
Allen D. (2014) Lost in translation? 'Evidence' and the articulation of institutional logics in integrated care pathways: from positive to negative boundary object? Sociology of Health & Illness, 36, 6: 807- 822.
Ament B, de Vugt M, Verhey F, Kempen G. (2014) Are physically frail older persons more at risk of adverse outcomes if they also suffer from cognitive, social and psychological frailty? European Journal of Ageing, 11: 213-219.
Degeling P, Maxwell S, Ledema, R. (2004) Restructuring clinical governance to maximise developmental potential. In Gray A, Harrison S (eds) Governing Medicine: Theory and Practice. Oxford: Oxford University Press.